Provider Demographics
NPI:1942538160
Name:ATHANASIUS, PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:ATHANASIUS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:POLA
Other - Middle Name:
Other - Last Name:AWAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1122 E LINCOLN AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-1907
Mailing Address - Country:US
Mailing Address - Phone:714-282-9131
Mailing Address - Fax:
Practice Address - Street 1:1122 E LINCOLN AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-1907
Practice Address - Country:US
Practice Address - Phone:201-952-3753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-29
Last Update Date:2013-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024287001223G0001X
CA596411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice